A survey in the United States in the 1970’s and another survey in India in the 1990’s showed that the general public of both countries held judges to be the most honest and the most highly respected among all professionals. Doctors came second in their estimation in both the surveys. All other professionals ranked lower than the judges and the doctors.

However it has been the misfortune of all of us that quite recently we have witnessed a very undesirable trend when the medical profession is no longer held by non-medical public in the very high esteem in which it was held earlier.

Members of the public often accuse the doctors of charging very high fees for professional services. A doctor, especially a specialist has to study at least ten years after leaving school to get his undergraduate and postgraduate degrees. He has to work under very difficult conditions for another five to ten years before he can get a decent income. This is true whether he is in service or in private practice. By this time he is 35 to 40 years old and has only another 20 years of active earning before him, to bring up his children and to save money for his own retired life.

One of our main problems is that the vast majority of us in the medical profession cannot communicate effectively. We are unable to convince the public, the media and the government that our stand is correct. Very often most of us are apathetic and do not try to convince them either. So we are accused unjustly of unethical standards in charging fees.

One of the biggest myths perpetrated by many politicians, many government officers, some of the other professionals and even by the media is that all the doctors earn a very large amount of money and good deal of it by unjustified means. It is perhaps possible to devote an entire oration to explode this myth.

I have been in neurosurgical practice in this country during the past 40 years. I will confine myself to pointing out briefly how the cost of medical treatment and income of doctors has risen only by 5 to 15 times compared to the cost of living which has risen 40 to 100 times in different areas during the same period.

The real income of doctors has fallen to one fourth of the previous level during the past four decades.

Putting it differently a doctor with 40 years experience has to work at least 3 to 4 times harder and much longer hours at the end of his career to maintain the same standard of living he had at the beginning of his career. In fact he has to work even more as he has to support not only his wife but also his children and parents towards the latter part of his career.

The Hippocratic oath states " Whatsoever in the course of practice I see or hear that ought never to be published I will not divulge but will consider such things to be holy secrets".

Every profession has dilemmas regarding confidentiality. Very delicate situations can arise regarding confidentiality and disclosure between doctor and patient (in cases of malignancy diagnosis), between priest and penitent (in cases of adultery and AIDS) between lawyer and client (in cases of suspected robbery), between banker and customer (in cases of suspected cheating) and between minister and secretary (in cases of compromising the safety of the people).

Disclosure of confidential information is sometimes necessary when there is risk to the patient himself like suicide or accident, when there is risk of infection to others like spouses or classmates or when there is risk of danger to others like passengers or co- workers.

In the famous case of Tarasoff versus the Regents of the University of California, the patient told his psychotherapist of his intention to kill a girl. The psychotherapist did not convey the warning to the concerned persons. The patient did in fact subsequently murder the girl. The psychotherapist’s defense that to inform the victim would be against his duty of confidentiality to the patient was rejected by the court. The protective function of the privilege of confidentiality ends when public peril begins.

The Supreme Court of Canada held in 1980 that “Even if a certain risk is a mere possibility which need not be disclosed, yet if its occurrence carries serious consequences, for example paralysis or even death, it should be regarded as a material risk requiring disclosure”.

Even if the chance of a complication is very low it may be considered quite significant in special cases

a.       Possibility of 1% risk to recurrent laryngeal nerve in anterior cervical decompression in a professional singer.

b.       Possibility of 1% risk of blindness in the only seeing eye in a patient with suprasellar tumor.

c.       Possibility of 1% risk of drop foot in a lumbar disc excision in a dancer.

d.       Possibility of 0.1% risk to life if the patient is the only child of a mother who has been permanently sterilized.

CONFIDENTIALITY:

If the husband had azoospermia, would you inform the wife?

If the husband had gonorrhoea, would you inform the wife?

If the husband had HIV, would you inform the wife?

If a nurse’s error contributed to death, would you inform the relatives?

If an equipment failure contributed to death, would you inform the relatives?

If a consultant’s misjudgment contributed to death, would you inform the relatives?

If an unwed girl aged fifteen is found to be pregnant, would you inform the mother?

If an unwed girl aged twenty is found to be pregnant, would you inform the mother?

If a married lady whose husband is abroad is found to be pregnant, would you inform the husband?

Informing the patient and relatives of the correct diagnosis and dismal prognosis in cases of incurable illness -

Arguments for (If the truth is not told):

1. Patient may go “ doctor shopping” till he gets the correct diagnosis and in that process undergo repeated painful, costly and sometimes risky investigations.

2. Patient may suffer needless fear and anxiety that his prognosis is even worse than it actually is.

3. Patient may lose his trust in the physician when he finds out the truth. He may mistrust all statements and advice from the physician in future.

4. Patient is deprived of the opportunity to plan his remaining future life- treatment, employment, children's career and marriage, will, financial plans, charities, religious rites etc. etc.

Arguments against: 

(1) All hope would be extinguished in the patient’s mind. He may go into extreme    depression.

(2) Even otherwise it is an enormous psychological burden for most patients.

(3) Physician can never be hundred percent certain of diagnosis. So his information may be false.

(4) Progress of the same illness may vary widely from patient to patient.

(5) If patient does not wish to know the truth, why thrust it on him?

(6) If patient cannot really understand the full implication, why force the diagnosis on him?

When a patient has a malignant glioma of the brain and the spouse, parents or children ask me” Doctor is it cancer? How long will he live?” I have a simple method of answering. I tell them, what I have learnt from my teacher Professor Norman Dott.

“ If there are hundred patients with this type of tumor five of them may die soon after operation. Sixty of them may not survive more than eighteen months. However twenty of them are likely to survive up to three years. And the last five may even survive more than five years. Who knows in which category your patient is going to be? Let us hope he will in the last category: but let us also be prepared in case he falls into the first category”.

When you put it like that, you have given them the exact truth, you have warned them the patient may die soon after or within a few weeks of surgery but at the same time you have given them hope that the patient may in the lucky 5% who survive five years. The human brain always believes that there is a high probability of getting the one in thousand chance of lottery prize but does not believe there is reasonable probability of getting the one in ten chance of a road traffic accident while driving above the speed limit.

A fully conscious educated employed young lady refuses all food and drinks. Her husband has just deserted her. She is highly depressed but is otherwise quite normal. Her health has deteriorated to such a state that unless urgent measures are taken to prevent starvation and dehydration, her life may be in danger.

Can the family doctor admit her in a hospital against her wishes? Can she be sedated without her consent and given feeds by Rye’s tube, intravenous fluids and antidepressants? If only a distant relative, close friend or employer gives consent, can the doctor be protected in a later legal action against him? Is it enough if he takes a second opinion from another doctor, supporting his decision? Is he preventing attempted suicide or is he infringing on basic human rights? Should he obtain a court order to support his decision?

A young man who is underweight and is a known diabetic develops acute appendicitis. The surgeon suspects that the inflamed appendix may rupture any time and cause peritonitis. He advises emergency surgery to prevent this. In the meantime the patient has the relevant medical literature scanned on the Internet and requests that only antibiotics should be given. He refuses to undergo operative treatment.

The surgeon feels that for this particular patient conservative treatment is highly risky. The surgeon feels that surgery has to be done within an hour or two to save life and there is no time to transfer him to another hospital. The parents agree with the surgeon. The patient is adamant in his opinion.

Can the surgeon take the father’s consent and sedate and operate on the patient against his wish? Should the surgeon take an informed refusal from the patient and give only antibiotics? Should the surgeon refuse to treat the patient saying he does not agree with the proposed conservative line of management?

Mr. Quackenbush was a chronically ill elderly diabetic. He developed gangrene of both legs. The attending surgeons advised amputation in both lower limbs. The patient refused surgery. He felt he was going to die soon anyway and would rather die whole than live a little longer without his legs.

The surgeons tried to have him declared incompetent because of his “irrational” decision. The psychiatrist found that Mr. Quackenbush clearly understood his choices and their implications. The case was referred to a court.

The court held that the patient’s decision was rational under the circumstances and that the surgeons should not override the patient’s decision.

A sixty year old doctor is admitted with a history of sudden onset of right hemiparesis and dysphasia a few hours earlier. At the time of admission Glasgow coma scale score is 4 / 15. CT scan shows a large left hemisphere infarct. Within two days he loses all brain stem reflexes, which can be clinically elicited.  He is on a ventilator but his blood pressure is maintained without ionotropic support. His wife and daughter want all supportive measures to be continued and if needed ionotropic support and cardiac resuscitation. His two sons want all supportive measures to be withdrawn. Whose directions should the doctor carry out?

Some very difficult situations can arise when the doctor has to decide when to withhold treatment or withdraw treatment already started. These may be multiple congenital malformations, Incidentally found slow growing tumours, advanced malignancies, practically brain dead patients and post tumor excision situations. 

A girl aged one year with a lipomyelomeningocele in the lumbo-sacral region is brought with total paraplegia and double in-continence. She has  hydrocephalus and an Arnold Chiari malformation.  She is a  precious baby born after ten years of married life of very rich parents. The baby’s mental milestones are normal.

Should we operate on this child ?  Can we ever make her walk?  Because the parents can afford any expense , can we do multiple operations? How much money can we make the parents spend?  Not only money but time, energy and other resources of which the family is in great need. Is it ethical to operate ? Is it ethical to refuse to operate?

It is very easy to say that parents have to give the informed consent or refusal when you provide them with all the facts. Are parents always capable of taking such a decision? It can be very difficult because of

1.       Their young age, lack of education, poor knowledge and immaturity.

2.       Their emotional situation – the shock of facing the crisis. They expected the perfect child but the new arrival is not only imperfect but permanently disabled.

3.       The short duration of time available in which they have to take the decision. The parents have little time to digest the totally unfamiliar medical information showered upon them in the intensely emotionally charged atmosphere of the pediatric intensive care unit when they are suddenly told that the child will be paraplegic and incontinent, that an emergency operation has to be done within a day or two, that this operation will not cure the existing disabilities of paraplegia and incontinence and that the child may also develop a hydrocephalus or other problems in future requiring a second or even a third operation. 

Freeman said, in 1973 “It is imperative however that if one embarks on therapy it should be vigorous therapy”. And what does vigorous therapy involve?

Excision of myelomeningocele

Shunting for hydrocephalus

Periodical neurological, radiological and psychological assessment

Re-operation if needed for tethered cord

Another operation if needed for syringomyelia, Arnold-Chiari etc.,

Revision shunt when needed

Orthopedic care and operations
Plastic surgery in some cases
Urological care and operations
Treatment of associated medical problems
Physiotherapy
Continuous careful medical care throughout life
Counseling of patient, parents and family
Education of the family physician
Education of the child
Training for employment
Placement in suitable employment.

Closure of the back is the first step

Unless all the other subsequent steps are carried out successfully, the overall result is equally bad or sometime even worse than that of the untreated child.

If we are not treating the child surgically and waiting for the child to die and ‘nature to take its course’ –

where do we draw the line in medical treatment

     Should we treat meningitis when it occurs? How far do we go?

     Should we treat chest infection if it occurs? How far do we go?

     Should we treat urinary infection when it occurs? How far do we go?

     Should we treat renal decompensation when it occurs? How far do we go?

Would you accept the following from pharmaceutical, surgical, equipment manufacturing and other firms:

     Letter pads with company’s address',Drug samples,

     Pens, clocks, household items, suitcases, bags, X-ray lobby, BP apparatus, Medical books, Journals,

     Non medical books, journals

     Money for breakfast / lunches for departmental lectures, clinical meetings
     Travel tickets and hotel expenses for conferences, CME programmes
     Money for Awards for Best Paper in conferences
     Money for Conference Support – sponsoring sessions, souvenir advertisements,
     Sponsoring lunches / dinners.

Is not the cost of all the above passed on indirectly to the patient making health care more expensive for him?

Adapted from Guidelines issued by the American Medical Association Council on Ethical and Judicial Affairs (1991)

and by the American College of Physicians (1990).

Acceptable

Gifts that benefit patients (eg) text books, drug samples

Gifts of minimal value used by physician in his work (eg) notepads, pens

Subsidies for independently planned and controlled educational meetings

Not Acceptable

            Gifts of substantial value that do not benefit patients (eg) travel ticket
            Gifts with ‘strings attached’
            Gifts that might influence objectivity of clinical judgment.

Gifts and other amenities provided to doctors at meetings especially when they do not directly benefit patients or cannot be used in the doctor’s professional work (eg) alcoholic drinks, art objects as momentos.

Would you charge professional fees for any of the following?

1.              Practicing Doctor

2.          Qualified Doctor – now businessman

3.             Medical Student

4.             Dental Student

5.             Qualified Nurse

6.          Nursing Student

7.          Qualified Physiotherapist

8.          Physiotherapy Student

9.             Businessman whose son is a Doctor and accompanying patient

10.      Businessman who is a NRI doctor

11.      Businessman whose father is a doctor and accompanying patient

12.      Businessman whose father is a doctor in another town.

13.      Doctor’s poor servant whose bill is paid by the doctor.

14.      Doctor’s well to do family priest whose bill is paid by the doctor.

15.      Doctor who has medical insurance.

If a right to treatment exists, is there a right to demand treatment, which is futile? Once the physician recognizes a treatment is futile, how should he proceed? Inform patient / relatives?  Wait for them to bring it up?  Stop without consulting them?  Continue with informed consent?  Stop with informed refusal?

MEDICAL FUTILITY

 
Intervention A may be futile in a achieving goal X but may not be futile in achieving goal Y. The aim of medical treatment is not merely to cause a ‘beneficial’ effect on some portion of the patient’s anatomy, physiology or biochemistry but to benefit the patient as a whole with special regard to alleviation of symptoms, quality of life and duration of life. 
If you ask the relative “Do you want us to do everything possible?” he will of course answer “Certainly yes, doctor”. 

If you tell the relatives that CPR for a cardiac arrest in a severely head injured hypertensive diabetic decerebrate eighty year old patient who had been comatose for three weeks on a ventilator has less than a 1 in 1000 chance of making him recover ultimately, but will only prolong his ICU stay for a few more days, almost all the relatives would say “Please do not resuscitate, doctor”. 

Why do relatives want futile treatment to continue

1.       Ignorance about true prognosis – inform them correctly with repeated frank discussions.

2.       Confusion – because different specialists attending on the patient give different opinions.

3.       Mistrust – of the doctors, nurses, hospital

4.       Evading responsibility – due to fear of blame by other family members, or since someone else is footing the bill.

It has been our great good fortune in this life to become doctors and enter a very noble profession. Let all of us stand united and do our utmost so that the medical profession in our country will truly become the noblest of all professions and every public opinion poll will list us at the top even above the judges.